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lumbar spinal puncture (LP, Quincke puncture, spinal tap, rachicentesis, rachiocentesis)

Indications: 1) CNS infection/meningitis: bacterial, fungal, viral 2) Subarachnoid hemorrhage 3) carcinomatous meningitis: - lymphoma, leukemia, melanoma, breast & lung carcinoma 4) inflammatory conditions: - multiple sclerosis, Guillain Barre 5) miscellaneous conditions: - pseudo tumor cerebri, normal pressure hydrocephalus 6) introduction of diagnostic & therapeutic agents a) contrast media b) antibiotics c) chemotherapeutic agents d) anesthetics e) radionuclides Contraindications: 1) evidence of increased intracranial pressure a) papilledema b) focal neurologic signs c) CT suggests increased intracranial pressure* d) infected skin or tissue overlying puncture site 2) anticoagulated state a) increased prothrombin time b) reverse anticoagulation 1 hr prior to LP c) thrombocytopenia 3) no serious complications in 100 patients receiving dual antiplatelet therapy with clopidogrel + aspirin [7] Procedure: - a 20-22 gauge needle with stylet inserted is inserted using sterile technique into the lumbar cistern of the spinal cord for diagnostic or therapeutic purposes - atraumatic needles diminish incidence of headache after lumbar puncture (RR=0.4) compared with standard needles [6]* - the spinal cord ends at L1-L2 in adults, L3 in children - the needle is inserted into the L4-L5 or the L3-L4 interspace - the L2-L3 space may be used in adults - the superior aspects of the iliac crests marks the level of the L4-L5 interspace - local anesthesia with lidocaine is standard procedure & narcotic analgesia is usually greatly appreciated - opening pressure of the CSF may be measured with a manometer - normal pressures are 10-20 cm of H2O - opening pressure > 25 cm H2O with viral meningitis - opening pressure > 20-50 cm H2O with bacterial meningitis [5] - 1-2 mL of CSF is collected in tubes 1-3 & 4 mL of fluid is collected in tube for special studies - simulation-based education may improve LP skills [3] - ultrasound guidance reduces frequency of failed attempts [4] * conventional needles have their collection port integrated into the point, which cuts through tissue * atraumatic needles have a closed, pencil-like point, which tends to separate & dilate dural fibers - non-cutting collection port of atraumatic needle is further up the shaft - atraumatic needles diminish leakage of CSF after puncture [6] Radiology: 1) head CT prior to LP is indicated, except: - if clinically suspected meningitis, & low risk of abnormal CT [2] 2) indications for head CT prior to LP [5,9] a) suspected mass lesion b) immunosuppression c) history of CNS disease d) new-onset seizures e) altered level of consciousness f) focal neurologic deficit [9] g) papilledema 3) performance of a head CT prior to LP delays administration of antibiotics by about 1 hour Complications: 1) headache occurs 10-20% of the time - hydration, supine position & small gauge needle are most useful measures - autologous epidural blood patch for headache due to CSF leakage [5] 2) infection 3) bleeding - spinal hematoma (0.2% not significantly affected by anti-platelet agent or anticoagulant use) [8] 4) backache 5) epidermal transplant: stylet is used to prevent epidermal transplant into the spinal canal 6) paresthesias: use stylet, do not aspirate CSF or nerve roots 7) herniation:* a) avoid LP if mass lesion or acutely elevated intracranial pressure is suspected b) CT of head prior to LP to identify mass lesions

Related

cerebrospinal fluid risk factors for abnormal head CT

Specific

lumbar puncture for drainage of CSF traumatic tap

General

clinical procedure

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1065-67
  2. Journal Watch 22(2):17, 2002 Hasbun R et al Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 345:1727, 2001 PMID: 11742046
  3. Barsuk JH et al. Simulation-based education with mastery learning improves residents' lumbar puncture skills. Neurology 2012 Jun 6; PMID: 22675080 http://neurology.jwatch.org/cgi/content/full/2012/619/2
  4. Shaikh F et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: Systematic review and meta-analysis. BMJ 2013 Mar 26; 346:f1720. PMID: 23532866
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, 18. American College of Physicians, Philadelphia 2012, 2018.
  6. Nath S, Koziarz A, Badhiwala JH et al Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet. Dec 6, 2017 PMID: 29223694 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32451-0/fulltext - van de Beek D, Brouwer MC Atraumatic lumbar puncture needles: practice needs to change. Lancet. Dec 6, 2017 PMID: 29223693 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32480-7/fulltext
  7. Carabenciov ID et al. Safety of lumbar puncture performed on dual antiplatelet therapy. Mayo Clin Proc 2018 May; 93:627 PMID: 29573815 https://www.mayoclinicproceedings.org/article/S0025-6196(18)30102-2/fulltext
  8. Bodilsen J et al. Association of lumbar puncture with spinal hematoma in patients with and without coagulopathy. JAMA 2020 Oct 13; 324:1419 PMID: 33048155 https://jamanetwork.com/journals/jama/article-abstract/2771609
  9. NEJM Knowledge+ Question of the Week. Dec 22, 2020 https://knowledgeplus.nejm.org/question-of-week/5036/